Behavioral Treatments for Sleep Disorders: A Comprehensive Primer of Behavioral Sleep Medicine Interventions 1st

308 PART III | BSM Protocols for Pediatric Sleep Disorders [2] W.K. Silverman, A. Dick-Niederhauser, Separation anxiety disorder, in: T.L. Morris, J.S. March, (Eds.), Anxiety Disorders in Children and Adolescents, second ed., Guilford Press, New York, NY, 2004, pp. 164–188. [3] T.F. Anders, M.A. Keener, Developmental course of nighttime sleep–wake patterns in fullterm and premature infants during the first year of life: I, Sleep 8 (1985) 173–192. [4] M.M. Burnham, B.L. Goodlin-Jones, E.E. Gaylor, T.F. Anders, Nighttime sleep–wake patterns and self-soothing from birth to one year of age: a longitudinal intervention study, J. Child Psychol. Psychiatry 43 (2002) 713–725. [5] W. Anuntaseree, L. Mo-Suwan, P. Vasiknanonte, S. Kuasirikul, A. Ma-A. Lee, C. Choprapawan, Night waking in Thai infants at 3 months of age: Association between parental practices and infant sleep, Sleep Med. 9 (2008) 564–571. [6] D. Fehlings, Frequent night awakenings in infants and preschool children referred to a sleep disorders clinic: the role of non-adaptive sleep associations, Child Health Care 30 (2001) 43–55. [7] B.L. Goodlin-Jones, M.M. Burnham, E.E. Gaylor, T.F. Anders, Night waking, sleep–wake organization, and self-soothing in the first year of life, J. Dev. Behav. Pediatr. 22 (2001) 226–233. [8] J.A. Mindell, B. Kuhn, D.S. Lewin, L.J. Meltzer, A. Sadeh, Behavioral treatment of bedtime problems and night wakings in infants and young children, Sleep 29 (2006) 1263–1276. [9] B.A. Iwata, G.M. Pace, G.E. Cowdery, R.G. Miltenberger, What makes extinction work? An analysis of procedural form and function, J. Appl. Behav. Anal. 27 (1994) 131–144. [10] T.M. Reimers, D. Wacker, L.J. Cooper, Evaluation of the acceptability of treatments for children's behavioral difficulties: Ratings by parents receiving services in an outpatient clinic, Child Fam. Behav. Ther. 13 (1991) 53–71. [11] D.C. Lerman, B.A. Iwata, M.D. Wallace, Side effects of extinction: prevalence of bursting and aggression during the treatment of self-injurious behavior, J. Appl. Behav. Anal. 32 (1999) 1–8. [12] E.S. Petscher, J.S. Bailey, Comparing main and collateral effects of extinction and differential reinforcement of alternative behavior, Behav. Modif. 32 (2008) 468–488. [13] D.C. Lerman, B.A. Iwata, Developing a technology for the use of operant extinction in clinical settings: an examination of basic and applied research, J. Appl. Behav. Anal. 29 (1996) 345–382 discussion 383–385. [14] B.F. Skinner, The Behavior of Organisms, Appleton-Century-Crofts, New York, NY, 1938. [15] B.R. Kuhn, Sleep disorders, in: M. Hersen, J.C. Thomas (Eds.), Handbook of Clinical Interviewing with Children, Sage Publications, New York, NY, 2007, pp. 420–447. [16] C.B. McNeil, T.L. Hembree-Kigin, (Eds.), Parent–Child Interaction Therapy, second ed., Springer, New York, NY, 2010. [17] R.V. Burke, B.R. Kuhn, J.L. Peterson, Brief report: A “storybook” ending to children's bedtime problems – the use of a rewarding social story to reduce bedtime resistance and frequent night waking, J. Pediatr. Psychol. 29 (2004) 389–396. [18] C.T. Yancey, B.R. Kuhn, My child won't sleep!!: Using the excuse-me drill to increase bedtime compliance and self-initiated sleep onset, presented at: Annual Munroe-Meyer Interdisciplinary Poster Session; 2006, April; Omaha, NE. [19] B.R. Kuhn, M.T. Floress, T.C. Newcomb, Strategic attention for children’s sleep-compatible behaviors: Treatment outcome and acceptability of the “excuse-me drill”, presented at: Association for Behavioral and Cognitive Therapies. Orlando, FL, Nov., 2008. [20] L.L. Grow, M.E. Kelley, H.S. Roane, M.A. Shillingsburg, Utility of extinction-induced response variability for the selection of mands, J. Appl. Behav. Anal. 41 (2008) 15–24.

Chapter 31 | The Excuse-Me Drill 309 [21] M.B. Waters, D.C. Lerman, A.N. Hovanetz, Separate and combined effects of visual schedules and extinction plus differential reinforcement on problem behavior occasioned by transitions, J. Appl. Behav. Anal. 42 (2009) 309–313. RECOMMENDED READING J. Bailey, M. Burch, How to Think Like a Behavior Analyst, Lawrence Erlbaum, Mahwah, NJ, 2006. K.G. France, N.M. Blampied, Infant sleep disturbance: description of a problem behaviour process, Sleep. Med. Rev. 3 (1999) 265–280. J.A. Mindell, J.A. Owens, A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems, second ed., Lippincott Williams & Wilkins, Philadelphia, PA, 2010. The Journal of Applied Behavior Analysis routinely publishes studies on the clinical application of fundamental principles of behavior-change.

Behavioral Treatments for Sleep Disorders. DOI: © Elsevier Inc. All rights reserved. 311 10.1016/B978-0-12-381522-4.00032-8 2011 Day Correction of Pediatric Bedtime Problems Edward R. Christophersen University of Missouri at Kansas City School of Medicine and Staff Psychologist, Children’s Mercy Hospital and Clinics, Kansas, MO Kathryn Harnett McConahay Pediatric Associates, Kansas City, MO PROTOCOL NAME Day correction of pediatric bedtime resistance. GROSS INDICATION Although ignoring tantrums/fussing is perhaps the most effective procedure for children who resist going to bed, many parents report that they “cannot stand to ignore the pleas of their children at bedtime”. Day correction of bedtime problems encourages parents to begin ignoring their child’s inappropriate behavior earlier in the day, when presumably the parents have more stamina or willpower, and can experience success with the procedure under less trying circumstances than bedtime. SPECIFIC INDICATION In order for children to be able to fall asleep on their own, either at bedtime or after a night waking, they must be able to calm themselves enough that they are able to fall asleep. The day correction of bedtime problems procedures facilitates the acquisition of these self-calming procedures during the day, when many more opportunities exist for such learning to occur under much better conditions. CONTRAINDICATIONS We have encountered parents in our clinic who are absolutely adverse to hearing their child exhibit distress of any kind. In those cases where a child lacks good self-quieting skills, procedures such as ignoring and its many variations Chapter 32

312 PART III | BSM Protocols for Pediatric Sleep Disorders may be doomed to fail since they require that the child exhibits a skill that is either not in his or her repertoire, or that may be present but is not evidenced in the presence of a parent. RATIONALE FOR INTERVENTION One of the most common concerns that parents of young children have is that they cannot get their children to bed at night, or their children wake up in the middle of the night and cannot get back to sleep by themselves. The vast majority of the time, these problems stem from the fact that such children do not have self-quieting skills. Self-quieting skills refer to children’s ability to quiet themselves when they begin to get upset about something. Most of the time, children with bedtime problems have had help or assistance from their parents in quieting at bedtime. This help may consist of nursing the child to sleep, rocking the child to sleep, lying down with the child, or allowing the child to drift off to sleep in the parents’ bed. The day correction method targets critical skills that are needed by young children during the day and night. Once children have developed selfquieting skills during the day, and have had at least 1 week to practice these skills, they can usually learn to self-quiet at night within 3–4 nights [1]. Building self-quieting skills appears to be crucial in an infant’s development, because the skills teach a baby to adapt to his environment. As Brazelton (p. xi) said, “the job for parents is to learn the fine line between when to intervene and when to leave the baby alone to find his own competent behavioral pattern of self-calming.” [2]. The beauty of the day correction procedures [1] is that we are able to demonstrate them during an office visit, and observe both the parent and the child’s reaction to them. If, after the office demonstration, it is apparent that the parent(s) will not be able to follow through with the procedures, then one of many alternatives can be offered to the parent(s), such as the other bedtime protocols described in this book. STEP BY STEP DESCRIPTION OF PROCEDURES Encouraging the Development of Self-Calming Skills Although the disciplinary procedure referred to as “time-out” has been around for almost 50 years, many parents have found that, in their words, “it doesn’t work”. One reason that we believe that it doesn’t work is that parents are using time-out to coerce or force their children to stop engaging in behavior that the parents don’t like or don’t want to see continued. The reason that many children “misbehave” is that they don’t have the skills for dealing with situations that they don’t like; they don’t have the skills for self-quieting, or, as it applies to adults, “coping skills”. We sometimes see this referred to as “anger control skills”, and these children are often said to have “bad tempers”, to be “strong willed”, or to be “difficult children”. Many parents, with the best of intentions, will put a great deal of effort into trying to convince their children, using

Chapter 32 | Day Correction of Pediatric Bedtime Problems 313 lecturing, explanations, and reasoning, into behaving differently. When this fails, they move into what we refer to as their “coercive mode” – that is, they are going to get the child to behave the way they want the child to behave, no matter what it takes. This often leads to direct confrontations that are unpleasant for both parent and child, and usually accomplish nothing beneficial. And, during this process, the parents are unwittingly making the situation worse by modeling coercive behavior for their child. In order to educate parents about the importance of shifting their focus from coercion to teaching, we are now recommending that parents begin giving their children the opportunity to learn “self-quieting skills”. There are several major components to teaching these skills: 1. Reduce nagging, lecturing, threatening, and warnings as much as possible – preferably eliminate them completely. 2. Provide the child with a great deal of brief, non-verbal, physical contact – usually, we recommend 100 brief physical touches a day in addition to normal caregiving activities. These touches are not meant to be rewards; rather, they are meant to let the child know, non-verbally, that he or she is loved. The reason for insisting that such contact be “non-verbal” is our experience that talking to children when they are engaged in a task often disrupts them enough that they never complete the task. 3. Use brief, non-emotional “chill-outs”. This is usually in the form of “chillout interrupting”. For example, if the parents have been providing the child with a lot of brief, non-verbal physical contact when the child wasn’t bothering them, then when the child does interrupt the parent, all the parent needs to say is “chill out interrupting”. Then, it’s extremely important that the parent ignores the child until he or she is quiet, or has regained his or her composure. During these “chill-outs”, the parent should refrain from all warnings, nagging, and reminders of what the child did or did not do. Basically, the parent should strive to completely ignore the child during a chill-out, until the child has calmed down. During the chill-out period, the child does not exist. No eye contact. For chill-out to end, the child must calm him- or herself down or gain control for 2–3 seconds, or turn 18 years old – whichever comes first. The child may call his or her parents names, strike them, or have a tantrum on the floor, but until the child calms down he or she does not exist. At first this will not be easy for most parents to do; that’s why we typically demonstrate these procedures during an office visit. Most parents have never seen the “other side of a tantrum”. After most children do self-calm, they are typically quite pleasant and cooperative, even cuddly. But because so many parents give in to tantrums, either by giving their child what the child wants or assisting the child in calming down, they never get to see how their child behaves after self-calming. While the parent is ignoring the child, the child (1) needs to be able to see his or her parent, (2) see that the parent is not upset, and (3) see what the child

314 PART III | BSM Protocols for Pediatric Sleep Disorders is missing out on. When demonstrating these procedures during an office visit, we will engage the parent in a conversation of mutual interest that has nothing to do with the child’s behavior, often having to do with the parent’s vocation, vacation, or something remarkable going on in their lives. Remember, we are giving the child multiple opportunities to learn selfcontrol – a skill that will be used throughout life. After the child gains control, or calms down for just 2–3 seconds, we prompt the parent to resume time-in. We remind the parent that there is no need to remind the child what he or she did prior to the chill-out, or to discuss the chill-out. Even if it takes an individual child a couple of days or a week to learn how to calm him- or herself down, having this skill can help to make the household a much more pleasant place to live. Over time, the child’s time to chill-out should gradually be extended from the original 2–3 seconds up to about 30 seconds. This process typically takes place over a period of a week or two. POSSIBLE MODIFICATIONS/VARIANTS When we see children who present with temper tantrums, and we have taken reasonable efforts to rule out developmental delays and reactive attachment disorder, we often elect to demonstrate for parents how to effectively NOT respond to temper tantrums – or, as it is often called in the literature, ignore the tantrum. This typically involves waiting (usually a short time) for something to happen that the child reacts to with a tantrum, then instructing the parents to ignore the tantrum while we filibuster by talking to the parents to distract them while they are attempting to ignore their child’s fussing. Predictably, the children engage in the behaviors that have worked for them at home to get their parent to re-engage with them, allowing us to see, firsthand, what parental behaviors have been maintaining the tantrums at home. Christophersen (2003), available from the American Psychological Association, is a videotape/DVD demonstration of these procedures [3]. In this videotape, the author demonstrates with a young mother the process of ignoring her toddler’s protests during a tantrum until he self-calms and then she is immediately prompted to pay attention to him again. Such a process provides the parents with the confidence that the procedures will work as described because they have seen them work. A crucial part of this demonstration is that the child almost always calms down and starts to engage in some play behavior, whereupon we prompt the parent to resume paying attention to the child; this allows us to point out that there is “no residual effect”. Not only are the children not mad at their parents for ignoring them; they are typically more affectionate than they were prior to the tantrum. Often, this is the first time the parents have seen the child stop a tantrum by him- or herself, and, more importantly, the first time they have seen that the tantrum did not harm their child. This can be empowering to parents who believed all along

Chapter 32 | Day Correction of Pediatric Bedtime Problems 315 that their child wasn’t capable of stopping his or her own tantrum. We have used this office demonstration with a wide variety of populations, including children referred for management of general behavior problems secondary to being born with cardiac problems (e.g., transposition of the great vessels) that mandated, at least until surgery had successfully corrected their congenital condition, that parents attend to their every whim so that they did not cry unnecessarily. In these situations, our experience has been that the tantrums are always brief, probably owing to the child’s getting exhausted very quickly and thereby losing the drive to continue with the tantrum. In addition to working to encourage the development of self-calming skills during the day, we incorporate some pretty standard procedures from the sleep literature, including: 1. Instruct parents to wake the child up at about the same time every morning. Be sure that the parent gets the child up while he or she is still playing quietly, instead of waiting until the child is crying. 2. The child should be put to bed at about the same time every night, alone, awake, and tired. 3. Parents should ensure the child has his or her meals at about the same time every day. 4. Parents should ensure that the child gets vigorous exercise every day. 5. Encourage parents to use time-out during the day for most misbehavior. Time-out should not be over until the child has self-quieted. Make sure that the parents are not avoiding any opportunities to use time-out. Every timeout helps with self-quieting skills. 6. Encourage parents to adopt a bedtime routine for the last 30 minutes before bedtime that is quieting to the child, and to follow a similar routine every night. It’s best to not vary from the routine until good bedtime habits are well established. 7. Parents should use time-in during the day whenever their child is engaged in an activity that they consider acceptable. 8. Instruct parents to place several soft toys in their child’s bed that can ultimately be used as “transition objects”. 9. If parents do feel the need to check their child during the night, suggest that they refrain from talking to the child or turning on the light, and refrain from picking the child up or tucking the child in again. When children who are referred for sleep issues present with significant behavior problems, a clinical decision must be made, based upon adequate assessment of the sleep issues as well as the behavioral issues, about the role that the sleep issues play. In many instances, addressing the sleep issues first can help with the resolution of the behavioral issues, and in some cases working on the behavioral issues first can help with the resolution of the sleep issues.

316 PART III | BSM Protocols for Pediatric Sleep Disorders PROOF OF CONCEPT/SUPPORTING DATA/EVIDENCE BASE Edwards and Christophersen [4] reviewed some of the published studies on ignoring as a treatment procedure, pointing out that although extinction was the most effective procedure in the behavioral treatment literature, many parents reported that they could not do it or chose to not do it. Edwards [5] was the first to provided reliable preliminary data (using time-lapse videotape recordings [6]) to suggest that parents can be instructed to encourage the development of sleep-onset skills by setting occasions for their child to learn self-quieting skills during the day. Similarly, Harnett [7], using a multiple baseline design across six young children, showed a rapid decrease in the amount of child protest and parental attention to the child at bedtime. The six children averaged protests during 48 percent of the intervals during baseline (with a range from 0 to 76 percent). The next condition, Extinction with Clinician Assistance, decreased these percentages to a mean of 30 percent. Subsequent Parent Implementation without Clinical Assistance, over the next 4 days increased this slightly to an average of 32 percent. In the followup condition, child protests continued at a low rate of 21 percent with a range from 0 to 24 percent. These findings were maintained at 1-month follow-up for five of the six families. Social validation measures showed that parents were very satisfied with all components of the treatment package, and would recommend this intervention to a friend with a similar problem. ACKNOWLEDGMENT Preparation of this protocol was supported, in part, by a grant from the Katherine B. Richardson Associates Fund, Children’s Mercy Hospitals and Clinics. REFERENCES [1] E.R. Christophersen, Beyond Discipline: Parenting that Lasts a Lifetime, second ed., Overland Press, Shawnee Mission, KS, 1998. [2] T.B. Brazelton, Foreword, in Sammons WA, The Self-Calmed Baby: A Revolutionary New Approach to Parenting Your Infant, Little Brown & Co., Boston, MA, 1989. [3] E.R. Christophersen, Parenting Young Children, Part of the Relationships. APA Psychotherapy Video Series, APA, Washington, DC, 2003. [4] K.J. Edwards, E.R. Christophersen, Automated data acquisition through time-lapse videotape recording, J. Appl. Behav. Anal. 26 (1993) 503–504. [5] K.J. Edwards, The use of brief time-outs during the day to reduce bedtime struggles, Diss. Abstr. Int. 54 (1993) 2181. [6] K.J. Edwards, E.R. Christophersen, Treating common sleep problems of young children, J. Dev. Behav. Pediatr. 15 (1994) 207–213. [7] K.J. Harnett, An analysis of daytime and bedtime interventions for sleep-onset problems, Diss. Abstr. Int. (1994) 53.

Chapter 32 | Day Correction of Pediatric Bedtime Problems 317 RECOMMENDED READING E.R. Christophersen, S.L. Mortweet, Treatments that Work with Children: Empirically Supported Strategies for Managing Childhood Problems, APA Books, Washington, DC, 2001. E.R. Christophersen, S.L. Mortweet, Parenting that Works: Building Skills that Last a Lifetime, APA Books, Washington, DC, 2003 (translated into Italian, Korean, and Icelandic). J.A. Mindell, J.A. Owens, A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems, Lippincott, Williams & Wilkins, Philadelphia, PA, 2003. S.L. Mortweet, E.R. Christophersen, Coping skills for the angry/impatient/clamorous child: a home and office practicum, Contemp. Pediatr. 21 (2004) 43–55.

Behavioral Treatments for Sleep Disorders. DOI: © Elsevier Inc. All rights reserved. 319 10.1016/B978-0-12-381522-4.00033-X 2011 Graduated Exposure Games to Reduce Children’s Fear of the Dark William L. Mikulas Department of Psychology, University of West Florida, Pensacola, FL PROTOCOL NAME Graduated exposure games to reduce children’s fear of the dark. GROSS INDICATION This intervention is indicated for children with fear of the dark. SPECIFIC INDICATION The games are particularly useful for darkness fear in children approximately 4–10 years old. This fear may manifest in many ways, including statements about being afraid, crying at night-time, clinging to parents in dark situations, trembling when in or approaching dark situations, having tantrums at bedtime, refusing to sleep in a bedroom alone, insisting on a parent staying in room until the child is asleep, insisting on lights being on, having restless nights, and frightened calling out to parents. CONTRAINDICATIONS Fear of the dark needs to be assessed within the context of other behavior problems and the dynamics of the family. Other behaviors may need to be treated first or in conjunction, including: l stress that accentuates fears; l resistance to going to bed; l attention-seeking and related reinforcement; l sleep disorders; l night terrors. Chapter 33

320 PART III | BSM Protocols for Pediatric Sleep Disorders RATIONALE FOR INTERVENTION Fear of the dark is the most common fear in children aged 4–7 years. It is often confounded with going to bed, time to get to sleep, calling to parents, and/or getting into the parents’ bed. These often lead to child–parent problems and family stress. Parents’ frustration and anger may lead to other problems, including child abuse [1]. Exposure therapy is now a well-established successful behavioral therapy for anxiety disorders, particularly simple and/or social fears [2–4]. The reduction of affect is due to respondent conditioning, but, in addition, “exposure therapy” usually includes operant and modeling components. We have explicitly dealt with all these components in our games, instructions to the parents, and storybook (discussed below). The proposed treatment is carried out by the parents in the home, which generally makes the treatment more effective and much less expensive than treatment by a professional in a clinic. The treatment program is also a powerful way to teach parents basic behavioral parenting skills that they can apply in many situations. This includes the use of reinforcement, shaping, modeling, and games. The treatment is brief and fun (which is very important with children), as opposed, for example, to desensitization components of progressive muscle relaxation and imagined scenes, which many children find difficult and boring. The intervention can potentially catch the fear early when it is easier to treat, because parents might wait longer until the fear-related problems get worse before considering professional therapy. The children learn basic selfcontrol skills they can apply in many situations, and this, coupled with their self-mastery of the fear of the dark, is a powerful way to increase their overall self-concept, self-esteem, self-efficacy, and internal locus of control [5]. STEP BY STEP DESCRIPTION OF PROCEDURES The exposure consists of a sequence of games, most of which involve gradually spending more and more time in the dark. Since parents coordinate and perhaps model these games, the first step is instructing the parents. We use written instructions, but it could also be done in person, individually or in a group. Instructions and education include the nature of fear of the dark, rationale for the treatment, and general related advice, such as avoiding scary movies and television, particularly before bedtime. Behavioral instructions include the use of reinforcement (e.g., praise, smiles, hugs, tangible reinforcers), the logic of shaping (e.g., gradually increasing time in the dark), and how to adapt the materials to the child’s needs and interests. Weekly phone calls at a preset time and/or e-mails between parent and professional are important to stay in contact, answer questions, and provide support. In some cases, parents are instructed in how to keep various types of records related to the program. This might be done for research, to demonstrate change, to check on the children’s

Chapter 33 | Graduated Exposure Games to Reduce Children’s Fear of the Dark 321 and parents’ progress, and/or to encourage and monitor shaping. One measure is based on the child’s approach/avoidance to dark situations that are fearful to that child – for example, how close will a child come to going into a dark room, or how long will the child stay in the dark room before needing to come out? This could be coupled with the child’s self-report of fear on a five-point scale. Great individual differences in the specifics and intensity of fear of the dark require that parents adapt choice and frequency of games to their children. Shaping is continually emphasized. Ask if the child thinks he or she can play the game. Encourage, but do not force. If the child is not ready, break the game into smaller steps or skip the game. As a general rule, stay with the game as long as the child is interested and progressing. Move on when the child is ready, but freely return to previous games. Next is the sequence of games that we have used. Obviously, the games could be modified or replaced for children of different ages, interests, or cultures. The games should generally be played in order, but the child does not have to master one before going on to the next. l Blindfold game. The blindfolded child tries to find large pieces of furniture or an easily placed toy in his room. Parents are instructed in shaping (gradually making the toy harder to find) and reinforcement (e.g., hugs and praise). l Puppet game. The child learns to relax by tensing and relaxing muscles in the order of arms, hands, legs, and neck. The image is one of a marionette who tenses up when strings are pulled and then relaxes when the strings are released. l Toy-in-the-room game. The child goes into a dark room to get a toy from a designated place. Shaping and reinforcement are again emphasized, as in the blindfold game. l Animal friends game. In a dark room, the child guesses the animal who would make the animal sound that a parent makes from another room. It is suggested that parents begin with easily identified sounds and not make scary sounds. Shaping is accomplished by lengthening the time the child lies in the dark waiting for the next sound. l Animals-on-the-wall game. Parents are shown how to make hand shadows of a goose, dog, bird, and camel. In the child’s darkened bedroom, parent and child make various shadows on the wall in the beam of a flashlight. Scary shadows are discouraged. l Toy-in-the-dark-game. This is similar to the toy-in-the-room game, except the child is not told where in the dark room the toy will be. Shaping and reinforcement are again stressed. l Flip-the-switch game. When a parent yells “Go!” from an adjacent room, the child in the bedroom gets up from the floor, turns off light, and goes to lie in bed before the parent arrives to turn light back on. Shaping includes how long the child stays in the dark until the light goes back on.

322 PART III | BSM Protocols for Pediatric Sleep Disorders l Find-the-noisy-box game. The game begins in a totally dark house, with the child lying in his or her bed. A parent in another room shakes a cereal box. The child finds the parent by going through the dark house turning on light switches. Shaping occurs through increasing the difficulty of finding the parent, and lengthening the time the parent waits before shaking the box. l Puppet game. This relaxation exercise is now expanded to include arms, legs, face, forehead, neck and shoulder, stomach, and toes. POSSIBLE MODIFICATIONS/VARIATIONS For the purpose of this chapter the games are presented as a separate and effective treatment, but in our complete program the games are embedded in a storybook called Uncle Lightfoot (see “Recommended Reading”, below). The story tells of Michael, a young boy with a fear of the dark, who goes to visit his “Uncle” Lightfoot, an Indian living in the country. Throughout the fun adventures of the story, Lightfoot plays various related games with Michael – the games described above. Through the games, Michael overcomes his fear and is proud of his new skills. Children greatly enjoy the story, and almost always want to have it re-read to them. Michael is a coping model who overcomes his fears, is pleased with his accomplishments, and is rewarded by others. Thus, a modeling component to reduce fears is added to the exposure-based games. Most of the children who hear the story want to play the games that Michael played. In addition, seeing where the games lead in a positive context can help reduce resistance that some fearful children or parents may have about exposure treatments. Relative to shaping and use of hierarchies, as the story progresses situations are more and more potentially anxiety-producing, and they become more difficult and involve more encounters with the dark. The book and games have gone through many revisions, based on research and feedback from parents. Instructions to parents include use of the book and games. The book should be read at night, as much or little as is appropriate and desired. One approach is to allow the child to play the games immediately as the story is being read to the child. Another approach is to read the book through several times before playing any of the games. Choice of approach may include such factors as severity of the fear and individual child preferences. PROOF OF CONCEPT/SUPPORTING DATA Research on earlier versions of the materials found them to be effective, fun, and inexpensive [6,7]. There were many very dramatic cases of behavior change. Combining all subjects, there were statistically significant changes due to the treatments – changes that were significantly different than for control subjects, such as a parental attention control group. Research by others on earlier versions of the materials found the book plus games to be significantly effective, with improvement slightly increased at a 12-month follow-up [8].

Chapter 33 | Graduated Exposure Games to Reduce Children’s Fear of the Dark 323 REFERENCES [1] B. Johnson, H. Moore, Injured children and their parents, Children 15 (1968) 147–152. [2] D.H. Barlow, L.B. Allen, M.L. Choate, Toward a unified treatment for emotional disorders, Behav. Ther. 35 (2004) 205–230. [3] R.J. McNally, Mechanisms of exposure therapy: How neuroscience can improve psychological treatments for anxiety disorders, Clin. Psychol. Rev. 27 (2007) 750–759. [4] B.A. Thyer, M. Baum, L.D. Reid, Exposure techniques in the reduction of fear: a comparative review of the procedure in animals and humans, Adv. Behav. Res. Ther. 10 (1988) 105–127. [5] W.L. Mikulas, The Integrative Helper: Convergence of Eastern and Western Traditions., Wadsworth, Pacific Grove, CA, 2002. [6] W.L. Mikulas, M.F. Coffman, Home-based treatment of children’s fear of the dark, in: CE Schaefer, JM Briesmeister (Eds.), Handbook of Parent Training, Wiley, New York, 1989, pp. 179–202. [7] W.L. Mikulas, M.F. Coffmann, D. Dayton, et al., Behavioral bibliotherapy and games for treating fear of the dark, Child Fam. Behav. Ther. 7 (1985) 1–7. [8] I. Santacruz, F.J. Mendez, J. Sanchez-Meca, Play therapy applied by parents for children with darkness phobia: comparison of two programmes, Child Fam. Behav. Ther. 28 (2006) 19–35. RECOMMENDED READING M.F. Coffman (2009). Uncle Lightfoot: Overcoming Fear of the Dark. [email protected].

Behavioral Treatments for Sleep Disorders. DOI: © Elsevier Inc. All rights reserved. 325 10.1016/B978-0-12-381522-4.00034-1 2011 Scheduled Awakenings: A Behavioral Protocol for Treating Sleepwalking and Sleep Terrors in Children Kelly Byars Divisions of Pulmonary Medicine and Behavioral Medicine/Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH PROTOCOL NAME Scheduled awakenings: a behavioral protocol for treating sleepwalking and sleep terrors in children. GROSS INDICATION Scheduled Awakenings (SA) has demonstrated efficacy for treating young children with chronic and severe sleepwalking (SW) and sleep terrors (ST) [1–5]. SPECIFIC INDICATION Most cases of SW and ST are benign, self-limited, and resolve spontaneously without the need for a targeted intervention such as SA [6–7]. SA is most appropriate when the following indications are present. 1. Patient has undergone a comprehensive clinical sleep evaluation confirming diagnosis [7]. 2. Non-rapid eye movement (NREM) parasomnia is evidenced by the following: l ambulation or terror episode (crying/loud screaming in conjunction with autonomic nervous system and behavioral symptoms of extreme fear) occurs during sleep [8] l evidence of altered state of consciousness (e.g., difficult to arouse; mental confusion if awakened; complete or partial amnesia for episode, dangerous or potentially dangerous behaviors) [8]. Chapter 34

326 PART III | BSM Protocols for Pediatric Sleep Disorders 3. Symptoms are chronic (persistence .3 months) [3,9]. 4. Frequency of SW or ST episodes is severe (episodes occur almost nightly, or at least multiple times per week) [3,9]. 5. SW or ST episodes occur at a highly predictable time each night [6,10]. 6. Parent or primary caregiver present in the home is fully aware of the demands of the treatment protocol and is willing to implement the protocol consistently over a treatment interval of at least 1–4 weeks. CONTRAINDICATIONS There are no published data specifically stating when SA is contraindicated for treating SW or ST. However, in clinical settings it is likely that the intervention would not be appropriate or effective, and/or would be quite difficult to implement, in the following circumstances: l when the patient has underlying primary sleep disorder (e.g., obstructive sleep apnea, periodic limb movement disorder); l when episodes are infrequent (less than weekly); l when the timing of events is unpredictable; l when episodes could be easily managed using standard management practices (see Table 34.1) [6,7,11]; l when sleep deprivation is a significant clinical issue, and targeted intervention to increase total sleep time takes precedence over intervening specifically to treat SW or ST [4,5,10]; l when parent or primary caregiver is unable or unwilling to implement the protocol. RATIONALE FOR INTERVENTION There are three primary hypotheses regarding the underlying mechanism for scheduled awakenings in reducing or eliminating SW and ST. First, it has been proposed that repeated scheduled awakenings alter the child’s sleep cycle in such a way that the altered underlying electrophysiology of partial arousal is either prevented or interrupted, and results in remission of the disturbing behavioral features of these events [1,2,4]. However, this proposed mechanism does not explain why partial arousal events do not return once SA is discontinued. Those in favor of this hypothesis have suggested that possibly the pathophysiology of NREM parasomnias is somehow corrected by repetitive awakening, and thus maintained even after SA is terminated. An alternative hypothesis suggests that the repetition of scheduled awakenings conditions the patient to spontaneously arouse (i.e., self-arousal) just prior to a parasomnia episode and thus avoids the event altogether despite the abnormal physiology [1]. A third possible mechanism has been proposed based on the increased susceptibility for partial arousal parasomnias in sleep-deprived

Chapter 34 | Scheduled Awakenings 327 TABLE 34.1 Standard Management Practices for Uncomplicated Sleepwalking and Sleep Terrors [10,11,14] Educate and reassure the child and family about sleepwalking and sleep terrors l Common in children l Benign condition l Not suggestive of psychological disturbance l Do not lead to psychological harm Safety precautions to consider l Lock all outside doors and windows l Heavy curtains at windows l Install security systems to signal if child attempts to leave home l Install motion alarms/bells on bedroom door to signal if child leaves bedroom l Discourage child from sleeping on top bunk l Consider moving mattress to floor l Remove any obstructions from bedroom or objects on floor that might cause injury (e.g., toys on floor) Sleep hygiene practices to promote optimal sleep and prevent/reduce likelihood of partial arousal events l Age-appropriate sleep schedule to promote adequate sleep l Consistent timing of sleep–wake cycle l Minimize parental intervention during events as this may lead to increased agitation or prolonged episode l Discuss potential triggers/exacerbating conditions (e.g., sleep deprivation, sleep in unfamiliar surroundings, illness) l Attempt to avoid/minimize triggers/exacerbating conditions individuals during rebound slow-wave sleep [4,5]. Two similar intervention studies documented unexpected and unexplained increases in the total sleep time of patients treated with scheduled awakenings. Based on this unanticipated finding, it was suggested that the efficacy of SA may simply have been due to increased total sleep time and a related reduction in the density of slowwave sleep [4,5]. STEP BY STEP DESCRIPTION OF PROCEDURES To date there has been limited published guidance regarding implementation of the procedures that constitute SA [12,13]. Integration of data from the published protocols [1–5] yields the following specific procedural variables that vary considerably across studies: (1) length of baseline assessment, (2) timing of awakenings, (3) method and duration of waking, (4) duration of treatment, and (5) rate of treatment tapering [12,13]. The implementation of SA generally follows three phases of treatment (see Table 34.2). While it is possible that a particular version of the treatment protocol has greater clinical utility, the current published literature does not definitively support one variation over

328 PART III | BSM Protocols for Pediatric Sleep Disorders the other. In order to best guide clinicians interested in using SA to treat SW and ST, the step by step procedures delineated below are a synthesis of all of the published studies. In clinical practice, it is advised that the treating clinician work with the caregiver implementing the treatment to establish concrete steps for implementation that are realistic for the family. This is best achieved by sitting down with the family before treatment is initiated and discussing the treatment plan. The clinician should assess whether or not the caregiver is comfortable with the plan, and confident he or she can implement the protocol. Baseline Monitoring/Treatment Planning It is important to note that typically children do not present to a clinician with a formal diagnosis, but with a clinical complaint or problem [7]. Thus it is critical that a child be formally evaluated before treatment is initiated. Detailed discussion of the assessment procedures required for making a clinical diagnosis of partial arousal parasomnia are beyond the scope of this chapter. In brief, the formal sleep evaluation should include a comprehensive sleep history [7], and polysomnography or EEG if nocturnal seizures are suspected. Ruling out an underlying primary sleep disorder (e.g., obstructive sleep apnea, periodic limb movement disorder) is essential. There are resources available that can guide the reader regarding the clinical assessment of sleep disorders [7,11,14,15]. Once a clinical diagnosis of SW or ST is confirmed, a detailed baseline assessment is required before implementing treatment. Observing and documenting the timing and frequency of partial arousal events is critical to the success of SA. Thus, a parent or caregiver must closely monitor and document the child’s sleep using a sleep diary (see Table 34.3). The sleep diary should be maintained on consecutive nights during a designated baseline period. Ideally, the baseline assessment should be completed in no less than 2 weeks. Once the baseline sleep diary has been completed, the clinician and family should review the data together. If (as delineated in specific indications above) the partial arousal episodes are frequent (i.e., almost nightly) and occur TABLE 34.2 Treatment (Tx) Phases of Scheduled Awakenings Protocol Phase of Treatment Specific Focus of Tx I. Baseline monitoring/Tx planning Clinical assessment, training in sleep monitoring, sleep diary assessment, develop treatment plan II. Active Tx Implement Tx, continue sleep diary assessment, adjust Tx as clinically indicated III. Tx tapering/termination Continue sleep diary assessment, decrease frequency of Tx based on frequency of events

Chapter 34 | Scheduled Awakenings 329 at a very predictable time each night, then the following steps should be followed for developing a treatment plan and instructing the caregiver regarding implementation: 1. Use the sleep diary to determine the typical time of onset for partial arousal episodes. 2. Use the sleep diary to calculate the average latency from the time the child falls asleep until the time of onset of partial arousal episodes. 3. Use the two data points above to discern the pattern of onset of partial arousal events and to determine the optimal timing for scheduled awakenings. 4. Awaken the child 15–30 minutes prior to the estimated onset time for the partial arousal episode. 5. Continue to keep a sleep diary throughout treatment so that treatment progress can be monitored. TABLE 34.3 Sleep Diary for Use with Scheduled Awakenings Protocol Name: ________________________________ Sunday Monday Tuesday Wednesday Thursday Friday Saturday Date: 1. Time child put to bed 2. Time child fell asleep 3. Time episode began 4. Duration of episode 5. Description of child behavior during episode 6. Description of parent responses to child during episode 7. Wake up time 8. Nap timing and duration (minutes)

330 PART III | BSM Protocols for Pediatric Sleep Disorders 6. Waking the child can be accomplished by light touching or verbal prompting. 7. Once aroused (evidenced by verbalization and/or eyes opening), allow the child to return to sleep. 8. Continue SA every night during the first week of treatment. 9. If no episodes occur during the first week of treatment, begin treatment fading (see discussion of treatment fading below). 10. If the child has any episodes during the first week of treatment, continue nightly scheduled awakenings during the second week of treatment and subsequent weeks until the child goes for an entire week without any episodes, and then begin treatment fading (see discussion of treatment fading below). Active Treatment Although the above procedures appear very straightforward, the actual implementation may prove challenging in some cases. Treatment challenges should be anticipated and discussed prior to recommending this treatment so that families are aware of treatment demands, and so that problems can be effectively managed when they occur. Research reports and anecdotal evidence suggest that parents may find the intervention difficult to implement, particularly if the intervention is applied at a time after the parent has already gone to sleep. This being the case, families may be eager to terminate the intervention as soon as they perceive improvement. Because there is no definitive length of treatment supported in the literature, treatment duration is managed based on the child’s response to treatment. It is recommended that clinicians advise parents to view treatment in weekly increments, and that decisions regarding modifying or terminating treatment should be made on a week-to-week basis. Because treatment response can be very quick, weekly consultation between family and clinician during treatment is recommended. There may be situations when the scheduled awakening triggers a partial arousal episode or results in the child becoming fully alert and remaining awake for a prolonged period. If this occurs on several consecutive nights, then the timing of the scheduled awakening should be advanced (i.e., moved earlier) by 15 minutes. Advancing the scheduled awakening time in a similar manner is also recommended if the child has a partial arousal episode before the scheduled awakening time. Delaying (i.e., moving later) the scheduled awakening time may be necessary in situations when partial arousal episodes do not resolve but occur at a later time during the night after treatment has been implemented. Treatment Fading/Termination There are no definitive guidelines for fading treatment based on the current empirical base. Of the five published treatment studies, only two dictated a fading schedule which was routinely accelerated by families (i.e., parents terminated therapy earlier than recommended). It is recommended that the

Chapter 34 | Scheduled Awakenings 331 treating clinician works closely with the family to dictate a fading schedule that is clinically appropriate and practical for the family to accomplish. An example of a fading schedule that is systematic and predictable is to start treatment fading after 7 consecutive nights without SW or ST, slowly reducing the number of scheduled awakenings per week by skipping a night during the week (complete awakenings on 6 out of 7 nights). During subsequent weeks, skip additional nights (1 per week – 5 of 7 nights, 4 of 7 nights, etc.) until scheduled awakenings have completely faded out [4]. Once scheduled awakenings have been completely discontinued, the treatment is completed. In the event that SW or ST reoccurs in the future, the protocol can be reinstituted. POSSIBLE MODIFICATIONS/VARIANTS A protocol using the same name (“scheduled awakenings”) [16–19] has demonstrated efficacy for treating problematic night wakings in infants, toddlers, and preschoolers [12–13]. The protocol requires close monitoring of nocturnal awakenings. After a clear pattern of awakenings has been established, scheduled awakenings are implemented 15–30 minutes prior to the time that nocturnal awakenings are predicted to occur. After the child is awakened, parents are instructed to attend to the child’s perceived needs (e.g., rocking, patting, feeding) until sleep is reinitiated. The time of the scheduled awakening is gradually delayed (i.e., moved later) so that continuous uninterrupted sleep is increased and frequency of spontaneous awakenings is reduced. SA is discontinued when the child is sleeping through the night. PROOF OF CONCEPT/SUPPORTING DATA/EVIDENCE BASE The efficacy of SA as a treatment for SW and ST has been demonstrated in young children (3–12 years of age) with parasomnias that were classified as severe (almost nightly occurrence) and chronic (persisting greater than 3 months). The evidence is limited to five published studies [1–5]. The first published reports were uncontrolled case reports that reported elimination of SW [2] and ST [1] after brief use (1 week or less) of SA. In each of these case reports, treated children had no reoccurrence of parasomnia at 1-year followup. More recently, three multiple baseline studies demonstrate the efficacy of SA for eliminating SW [3] and significantly reducing ST [4,5]. In each of these studies, parasomnias were eliminated or significantly reduced over longterm follow-up (6–12 months post-treatment). Based on established guidelines for rating psychological treatments using the weight of empirical evidence, SA is classified as a “promising treatment” for SW and ST [12]. REFERENCES [1] B. Lask, Novel and non-toxic treatment for night terrors, Br. Med. J. 297 (1988) 6648. [2] J.D. Tobin, Treatment of somnambulism with anticipatory awakening, J. Pediatr. 122 (1993) 426–427.

332 PART III | BSM Protocols for Pediatric Sleep Disorders [3] N.C. Frank, A. Spirito, L. Stark, J. Owens-Stively, The use of scheduled awakenings to eliminate childhood sleepwalking, J. Pediatr. Psychol. 22 (1997) 345–353. [4] V.M. Durand, J.A. Mindell, Behavioral intervention for childhood sleep terrors, Behav. Ther. 30 (1999) 705–715. [5] V.M. Durand, Treating sleep terrors in children with autism, J. Posit. Behav. Interv. 4 (2002) 66–72. [6] T. Mason, A.I. Pack, Pediatric parasomnias, Sleep 30 (2007) 141–151. [7] G.M. Rosen, D.P. Kohen, M.W. Mahowald, Parasomnias, in: M.L. Perlis, K.L. Lichstein, (Eds.), Treating Sleep Disorders: Principles and Practice of Behavioral Sleep Medicine, John Wiley & Sons, Hoboken, NJ, 2003, pp. 393–414. [8] The International Classification of Sleep Disorders, Diagnostic and Coding Manual, second ed., American Academy of Sleep Medicine, Westchester, IL, 2006. [9] International Classification of Sleep Disorders, Diagnostic and Coding Manual, American Sleep Disorders Association, Rochester, MN, 1990. [10] V.M. Durand, Sleep Better! A Guide to Improving the Sleep for Children with Special Needs, Paul H. Brookes, New York, NY, 1998. [11] J.A. Mindell, J.A. Owens, A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems, Lippincott Williams & Wilkins, Philadelphia, PA, 2003. 42–54. [12] B.R. Kuhn, A.J. Elliot, Treatment efficacy in behavioral pediatric sleep medicine, J. Psychosom. Res. 54 (2003) 587–597. [13] B.R. Kuhn, D. Weidinger, Interventions for infant and toddler sleep disturbance: a review, Child Family Behav. Ther. 22 (2000) 33–50. [14] R. Ferber, Assessment of sleep disorders in the child, in: R. Ferber, M. Kryger, (Eds.), Principles and Practice of Sleep Medicine in the Child, W. B. Saunders Company, Philadelphia, PA, 1995, pp. 45–53. [15] A. Sadeh, Clinical assessment of pediatric sleep disorders, in: M.L. Perlis, K.L. Lichstein, (Eds.), Treating Sleep Disorders: Principles and Practice of Behavioral Sleep Medicine, John Wiley & Sons, Hoboken, NJ, 2003, pp. 344–364. [16] R.J. McGarr, M.F. Hovell, In search of the sand man: shaping an infant to sleep, Educ. Treat. Children 3 (1980) 173–182. [17] C.M. Johnson, S. Bradley-Johnson, J.M. Stack, Decreasing the frequency of infants’ nocturnal crying with the use of scheduled awakenings, Fam. Pract. Res. J. 1 (1981) 98–104. [18] C.M. Johnson, M. Lerner, Amelioration of infant sleep disturbances: II. Effects of scheduled awakenings by compliant parents, Infant Ment. Health J. 6 (1985) 21–30. [19] V.I. Rickert, C.M. Johnson, Reducing nocturnal awakening and crying episodes in infants and young children: a comparison between scheduled awakenings and systematic ignoring, Pediatrics 81 (1988) 203–212. RECOMMENDED READING V.M. Durand, Sleep Better! A Guide to Improving the Sleep for Children with Special Needs, Paul H. Brookes, New York, NY, 1998. J.A. Mindell, Sleeping Through the Night: How Infants, Toddlers, and Their Parents Can Get a Good Night’s Sleep, Harper Collins Publishers, New York, NY, 2005. J.A. Mindell, J.A. Owens, A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems, second ed., Lippincott Williams & Wilkins, Philadelphia, 2010.

Behavioral Treatments for Sleep Disorders. DOI: © Elsevier Inc. All rights reserved. 333 10.1016/B978-0-12-381522-4.00035-3 2011 Imagery Rehearsal Therapy for Adolescents Barry Krakow Sleep & Human Health Institute, Maimonides Sleep Arts & Sciences, Ltd, Albuquerque, NM PROTOCOL NAME Imagery rehearsal therapy for adolescents. GROSS INDICATION Imagery Rehearsal Therapy (IRT) is indicated for treatment of chronic nightmares in adolescents, and for potential treatment of acute nightmares in adolescents. IRT is useful for various types of disturbing dreams, not necessarily those classically defined as nightmares, which nosologically include an awakening with a feeling of fear or anxiety. Repeatedly in research studies, it is clear that not all patients, adults or adolescents, awaken from their nightmares, which has thus promoted the term “bad dreams” or “disturbing dreams” for this subset. While there is some evidence that bad dreams and nightmares might reflect a difference in severity, we have found that IRT works well on both categories. SPECIFIC INDICATION There is reason to believe that chronic nightmares appear to be driven by a conditioning process – that is, they appear to function as a learned behavior, and IRT may be best suited for nightmares stemming from this process. However, this view is predicated on the fact that among trauma survivors who perceive their traumatic experiences as the sole precipitating cause or perpetuating influence on the problem there is less interest or willingness to attempt IRT, whereas among those who might report they are “tired of having nightmares” we see greater interest in attempting IRT. There are insufficient data to know whether the above information is simply an explanation of who will or who won’t respond to IRT, or just who will or who won’t attempt the use of IRT. Among adolescents, the same dichotomous thinking holds as well. Most adolescents seeking treatment for nightmares suffer from other psychiatric Chapter 35

334 PART III | BSM Protocols for Pediatric Sleep Disorders conditions, usually anxiety, depression, or PTSD. They may perceive nightmares as part of the psychiatric condition or they may be “tired of having nightmares”, and wonder whether something else (e.g., IRT) can help them. Moreover, because adolescents are closer to childhood than adults, they tend to resonate with instructions regarding the use of imagery in the mind’s eye, perhaps because they are not so far removed from the time when their imagination may have been used more regularly for make-believe and other fantasies common in younger children. While there are few (perhaps only one) controlled studies on IRT in adolescents, there are increasing anecdotal reports of its use in children and adolescents, and increasing interest in nightmares in the same populations. From social networking, it is clear that parents have used the IRT technique in children as early as 18 months of age, so it is likely more studies and reports will be forthcoming on the use of IRT in a broad range of children and adolescent age groups. CONTRAINDICATIONS There is clear evidence that any imagery technique can lead to overstimulation in susceptible individuals – for example, PTSD patients. Thus, in PTSD patients with extremely severe nightmares as well as daytime imagery dysfunction in the form of flashbacks, daymares, or traumatic memories, caution is strongly advised when considering an IRT program of therapy. Other contraindications would include individuals who report a complete inability to access their imagery system. There is no evidence that IRT works for other parasomnias such as sleep terrors, REM behavior disorder, or hypnagogic hallucinations. Among adolescents the same caveats hold, although, again because adolescents may be more in tune than adults with the concept and application of imagery, it is conceivable that more severe adolescent nightmare patients can be coached through an IRT program with a reasonable likelihood of success. However, it cannot be repeated often enough that the clinician must determine whether the co-morbid diagnosis (most often PTSD) is so severe that it must be the primary focus of therapy well before considering nightmare treatment. RATIONALE FOR INTERVENTION Nightmares are commonly viewed in children and adolescents as a maturational process that is unlikely to require treatment [1]. Scant attention is given to nightmares and nightmare treatments (for children or adolescents) in the medical, psychiatric, and psychological literature, not to mention the clinical setting [2]. Because of the conventional wisdom that nightmares in children and adolescents decrease with time, a nightmare disorder at this age is more likely diagnosed subsequent to severe psychosocial stress such as the death of a caregiver, divorce, sexual/physical abuse, or neglect [3]. Notwithstanding these views,

Chapter 35 | Imagery Rehearsal Therapy for Adolescents 335 there is a small body of research that indicates nightmares occur frequently in childhood and adolescence [4–7]. One study surveying a random sample of adolescents (mean age 17 years) demonstrated a prevalence of 6.8 percent for frequent nightmares [8]. Another study of 11- to 14-year-olds yielded a prevalence of 20 percent, although it did not employ random sampling methods [9]. This is consistent with a meta-analysis that indicates nightmare prevalence in children and adolescents is fairly high; rates ranged from a peak in early childhood of 42.2 percent at age 2.5 years, followed by a progressive descent toward adolescence with a final prevalence of 7.3 percent at age 16 years [10]. For nightmare chronicity in adults, 42 percent reported an onset before the age of 15 years and slightly more than one-half of adult chronic nightmare sufferers developed their problem before the age of 20 years. Thus, a substantial number of adolescents appear to suffer from chronic nightmares, and for many it appears likely that the problem persists into adulthood [10]. Morbidity associated with nightmares and related sleep disturbances in adolescence is not inconsequential. Manni and colleagues [11] divided a large sample of 17-yearold adolescents into two groups: poor sleepers (non-restorative sleep quality), and those who reported restorative sleep quality. They noted that nearly 50 percent of those in the poor-sleep group suffered from frequent nightmares, and of 15 dependent variables relating to sleep factors, nightmares attained the highest odds ratio at 62.1 (confidence interval 95%, 58.0–64.4) in their logistic regression model for predicting poor sleep. Nightmares may also represent a specific marker for a history of sexual trauma in abused children and adolescents [12]. Despite this potentially high prevalence of nightmares and their impact on sleep, there has been only one controlled treatment study (non-randomized), to our knowledge, assessing nightmare treatment in children or adolescents [13]. Halliday [14] lists several case reports that present individual patients treated with a variety of techniques, such as desensitization, play therapy, storyline alterations, extinction, or “face and conquer” (lucidity). Handler [15] successfully treated an 11-year-old with a combination of implosive therapy and a relationship approach. Cavior and Deutsch [16] used systematic desensitization to effectively treat a 16-year-old inmate for his recurrent nightmare. Palace and Johnston [17] utilized the dream reorganization approach on a 10-year-old boy with recurrent, traumatic nightmares, and Pellicer [18] utilized eye-movement desensitization and reprocessing for the treatment of nightmares in a 10-year-old. In the largest study on the treatment of nightmares in children and adolescents, Wile [19] describes the “auto-suggested dreams” approach that he used on 25 children and adolescents who had suffered from nightmares for various periods of time, ranging from a few days to a few months. The technique centered on the simple instruction: “Think about what you would like to dream about tonight”. The children tended to have improvement within a few weeks to a few months. Follow-up ranged from a few months to 5 years (median 1 year), with no relapses [19].

336 PART III | BSM Protocols for Pediatric Sleep Disorders Based on adult literature and treatment paradigms for PTSD, it would not be surprising to see future development of exposure-based treatments for nightmares in adolescents. In our work with adolescents, however, we have observed in one controlled study, and anecdotally in the clinical environment, that IRT has efficacy and effectiveness, and IRT is not primarily an exposurebased treatment, albeit the very process of discussing nightmares no doubt can be considered some degree of exposure [20]. IRT operates on the premise that nightmares may be a learned behavior. In some manner, a child or adolescent who initially responds to a daytime stressor with anxiety or fear and then disturbing dreams the same night or that week may be developing a “circuit” that works on the premise: “bad things  bad dreams”. One could argue that such a circuit clearly exists in that conventional wisdom and dream research frequently describe nightmares as a place to process adverse daytime experiences. The question arises then as to why the “circuit” continues to operate if someone has successfully processed the daytime experiences. PTSD patients with successful treatment of their PTSD may still report residual nightmares, which is a counterintuitive fact, given that the expectation is that when PTSD is treated effectively, say with exposure therapy, then surely nightmares (a symptom of PTSD) ought to disappear [21]. This persistence of nightmares in the face of other psychiatric interventions is one of the main issues that led our research teams to begin speculating on whether nightmares should be more accurately conceptualized as an independent or co-morbid sleep disorder in most cases of nightmare disorder [21]. From this vantage point, the question continuously arises as to why these nightmares stick, which has led to theories about disturbing dreams as a learned behavior. IRT is a therapy that specifically works to empower the patient to engage or re-engage their natural human imagery system and create new images for rehearsal, which we assume influence nocturnal images in some fashion to interrupt the nightmare cycle. How this process unfolds and whether what we are describing is valid are matters for future research. STEP BY STEP DESCRIPTION OF PROCEDURES An IRT program can be offered in three major steps: 1. Facts about nightmares 2. Practicing pleasant imagery 3. Imagery rehearsal treatment of nightmares. Facts About Nightmares The first step explores common questions chronic nightmare sufferers ask about their disturbing dreams, and includes discussion about how nightmares can affect

Chapter 35 | Imagery Rehearsal Therapy for Adolescents 337 one’s sleep. Discussion points focus on linking nightmares to untoward effects on sleep, which then helps the patient to appreciate that nightmares are “independent”, and can be directly treated. Remarkably, the majority of nightmare sufferers do not automatically assume nightmares are bad for their sleep. They tend to view nightmares as a mental health thing that’s occurring during sleep, but they may not be clear that it actually worsens sleep. We usually discuss: l the linkage of nightmares to sleep problems; l fear of nightmares provoking sleep onset insomnia; l fear of returning to sleep post-nightmare provoking sleep maintenance insomnia; l that nightmares appear to fragment sleep and thus degrade sleep quality. This first part of the program can also begin to raise questions about the cause of nightmares: l What is the initial cause of nightmares? l Why do nightmares persist in some people? l What might it mean if nightmares have not responded to treatment with medications or psychotherapy? l Is it possible to imagine that we have more control over nightmares than we might have thought possible? Practicing Pleasant Imagery The second step gives each participant the opportunity to attempt visualization exercises to assess his or her ability to create images and to monitor for unpleasant images. Seven simple behavioral techniques (thought stopping, breathing, grounding, talking, writing, acknowledging, and choosing) are taught, to cope with unpleasant images that might occur during any practice of pleasant imagery. This part of the program focuses on teaching the adolescent to engage or re-engage with his or her natural imagery system (for more details, imagery is discussed at length in Sound Sleep, Sound Mind, see Recommended reading, below). Key points raised include the following: l Imagery is a natural component of the human brain. l Imagery is accessed repeatedly throughout the day to solve problems – for example, remembering driving instructions, locating something misplaced, knowing what’s in the fridge before you go to eat it, and so on. l The capacity to actively engage one’s imagery system may take different forms, but it is most reliably understood as “active daydreaming” or “guided daydreaming”. l Imagery exercises are not meant to be intense efforts yielding meditative or hypnotic-like states; they may or may not be comfortable, but it is best to evoke pleasant images when re-engaging the system.

338 PART III | BSM Protocols for Pediatric Sleep Disorders l The goal is to help the individual realize that imagery is a naturally occurring form of “thinking” in the human mind, which is somewhat akin to the dream state because of its use of visual imagery and because images provide broader brushstrokes of what’s on your mind compared with verbal thoughts (self-talking). l Last, with practice of pleasant imagery, it becomes clear that the human mind can influence some of the images that emerge in the mind’s eye; therefore, if such images can be influenced in the waking state, might not such influence extend to the sleep state? Imagery Rehearsal Treatment of Nightmares The final step teaches the three-step process of selecting a nightmare, changing it with the instruction “change it anyway you wish”, and then rehearsing the new set of images (identified as a “new dream”) in the waking state. With the imagery rehearsal technique, participants are taught to write down the material for learning purposes, but they are encouraged to continue using the process mentally. If individuals believe that writing down the old nightmare and new dream is helpful to the process, then they are encouraged to continue in that manner. Participants are instructed to practice the technique (with the sole emphasis on rehearsing new dreams, not nightmares) for at least a month on a daily basis, 5–20 minutes per day, and to do so in the context of working with no more than two “new dreams” each week regardless of how many nightmares they experienced. In practice, this instruction seems to be followed about 50 percent of the time, in that one prior study showed that the average use of IRT post-treatment was every other day for the first month. We recommend follow-up at 4 and 12 weeks post-treatment to review progress, and the use of an outcomes questionnaire facilitates this process. Notes on the Application of IRT Pearls we have learned in the application of the IRT steps include the following: 1. Strongly discourage a patient who wants to select his or her worst, most vivid, most trauma replay-like nightmare on the first attempt at IRT. Such dreams may set the stage for failure, by overwhelming the patient with what amounts to unplanned desensitization. The goal is to learn a process called, “changing a nightmare to a new dream and then rehearsing the new dream”. 2. If at all feasible, avoid suggestions to the patient regarding the instructions “change the nightmare anyway you wish”. It’s the patient’s nightmare and it’s the patient’s mind; he or she has the ability to intuit some ideas on how to change it, and it’s not at all inconceivable that one empowering

Chapter 35 | Imagery Rehearsal Therapy for Adolescents 339 component of IRT is that it encourages the patient to shoulder the responsibility for designing the changes. It is as if the patient is taking charge at this moment, which may be a trigger to enhance self-efficacy. 3. In light of the above, we almost never offer example(s) to patients on what a changed dream might look like until they have attempted the process and reported on how it evolved for them. Later, in group format, for example, we’ll discuss “new dreams” among the patients, which gives them a chance to see that some changed the beginning, the middle, or end. Some change a few words, a few images, or just one thing. Some changed nothing at all, but they decided to feel differently about the dream content. Giving the patient a wide berth appears to have utility. 4. Tailor the three steps of the program to the patient. An adolescent with severe PTSD will likely need to spend meaningful time on all three steps to digest the material in order to embrace, or at least acknowledge, a new perspective on nightmares. However, some adolescents may need fewer of these coaching components because their imagery systems are already somewhat engaged or fairly well developed in ways that can more easily acquire and apply the three-step instructions for IRT, perhaps in just one session. POSSIBLE MODIFICATIONS/VARIANTS There are numerous variants of IRT, across all age groups, although most work has been done in adults. The major variations include the following: 1. Group vs Individual Treatment. There is a number of studies describing the use of IRT as a group treatment or individually, suggesting equivalency, but there are more randomized controlled trials (RCTs) using groups. 2. Longer vs Shorter Total Treatment Time. There is no established optimal length of treatment for an IRT protocol. We have generally used 7–10 hours for groups, and much less for individual treatment. For non-PTSD patients, as little as 1 hour might be needed for a chronic nightmare patient receptive to this form of therapy. 3. More vs Less Exposure Component to Therapy. This is a major area of interest because it was always assumed that IRT was really some form of covert exposure therapy, and undoubtedly it does create an opportunity for indirect exposure in that it engages a patient to at least think about the nightmare problem, but the IRT program initially developed by Kellner and Neidhart and continued by Krakow and Hollifield [22] de-emphasizes exposure as much as possible. On the other hand, Davis and Wright [23] have been developing an IRT variation with a greater exposure component. 4. Treating Chronic vs Acute Nightmares. It is very difficult to conduct research on acute nightmare patients, especially as nightmares would be expected to resolve spontaneously in a large number of cases. We recently

340 PART III | BSM Protocols for Pediatric Sleep Disorders published a case report on 11 US combat soldiers who were treated with IRT while serving in Iraq, of whom 7 responded with marked reductions in nightmares [24]. Future research needs to look at this area, because it raises the interesting question: Would early treatment of nightmares, a major re-experiencing phenomenon of PTSD, lead to some decreased risk for developing chronic PTSD? 5. Treatment Delivery Formats: Personal Encounter, Postal, Audiotape & Workbook. There has been some development of IRT formats beyond traditional clinical sessions. Marks [25] has been working with a postal version, which has been studied in a randomized controlled trial. Krakow has been working with an audio series and treatment workbook version, which has not been studied. PROOF OF CONCEPT/SUPPORTING DATA/EVIDENCE BASE Several review articles have appeared in the scientific literature in the past few years that either suggest or endorse IRT as a first-line therapy for the treatment of chronic nightmares. These articles, in various formats, list the evidence in a host of IRT studies by the various research groups who have undertaken such efforts. The five main reviews published between 2006 and 2008 were by Lancee et al. [26], Wittmann et al. [27], Lamarch and De Koninck [28], Spoormaker et al. [29], and Maher et al. [30]. However, to our knowledge, our single RCT on the use of IRT in adolescents reflects the only controlled study in this age group, and this study was a non-randomized controlled trial due to the logistical issues inherent in the collaboration between New Mexico and Wyoming researchers. Moreover, of 30 participants assigned to treatment and control groups, 11 dropped out or did not provide data, thus the results were based on 19 individuals (9 treatment, 10 controls). Statistically significant treatment effects for nightmares and nights per week of nightmares were very large, but there were no significant effects for changes in sleep or PTSD scores as seen in adult studies. Overall, the data support IRT for the treatment of nightmares in adolescents, but, given that this study appears to be the only controlled study conducted, replication is essential. REFERENCES [1] L. Terr, Nightmares in children, in: C. Guillemmault, (Ed.), Sleep and Its Disturbances in Children, Raven Press, New York, NY, 1987, pp. 231–242. [2] A. Vela-Bueno, E.O. Bixler, B. Dobladez-Blanco, et al., Prevalence of night terrors and nightmares in elementary school children: A pilot study, Res. Commun. Psychol. Psychiatry Behav. 3 (1985) 177–188. [3] G. Klackenberg, A prospective longitudinal study of children. Chapter XIV, Further studies of sleep behavior in a longitudinally followed up sample, Acta Paediatr. Scand. 224 (1971) 161–185.

Chapter 35 | Imagery Rehearsal Therapy for Adolescents 341 [4] J. Simonds, H. Parraga, Sleep behaviors and disorders in children and adolescents evaluated at psychiatric clinics, Dev. Behav. Pediatr. 1 (1984) 6–10. [5] L. Yang, C. Zuo, L.F. Eaton, Research note: sleep problems of normal Chinese adolescents, J. Child Psychol. Psychiatry 1 (1987) 167–172. [6] E. Hartmann, The Nightmare: The Psychology and Biology of Terrifying Dreams, Basic Books, New York, NY, 1984. [7] M. Schredl, R. Pallmer, A. Montasser, Anxiety dreams in schoolaged children, Dreaming 4 (1996) 265–270. [8] J. Vignau, D. Bailly, A. Duhamel, Epidemiologic study of sleep quality and troubles in French secondary school adolescents, J. Adolesc. Health 21 (1997) 343–350. [9] K. Lee, G. McEnany, D. Weekes, Gender differences in sleep patterns for early adolescents, J. Adolesc Health 24 (1999) 16–20. [10] D. Sandoval, B. Krakow, R Schrader, et al., Adult nightmares sufferers: can they be identified and treated in childhood?, (Abstr) Sleep Res. 26 (1997) 256. [11] R. Manni, M.T. Ratti, G. Marchioni, et al., Poor sleep in adolescents: a study of 869 17-year-old Italian secondary school students, J. Sleep Res. 6 (1997) 44–49. [12] A.P. Mannarino, J.A. Cohen, A clinical-demographic study of sexually abused children, Child Abuse Negl. 10 (1986) 17–23. [13] B. Krakow, D. Sandoval, R. Schrader, et al., Treatment of chronic nightmares in adjudicated adolescent girls in a residential facility, J. Adolescent Health 29 (2) (2001) 94–100. [14] G. Halliday, Direct psychological therapies for nightmares: a review, Clin. Psychol. Rev. 7 (1987) 501–523. [15] L. Handler, The amelioration of nightmares in children, Psychotherapy: Theory, Research, and Practice 9 (1972) 54–56. [16] N. Cavior, A. Deutsch, Systematic desensitization to reduce dream anxiety, J. Nerv. Ment. Dis. 161 (1975) 433–435. [17] E.M. Palace, C. Johnston, Treatment of recurrent nightmares by the dream reorganization approach, J. Behav. Ther. Exp. Psychiatry 3 (1989) 219–226. [18] X. Pellicer, Eye movement desensitization treatment of a child’s nightmares: a case report, J. Behav. Ther. Exp. Psychiatry 1 (1993) 73–75. [19] I. Wile, Auto-suggested dreams as a factor in therapy, Am. J. Orthospsychiatry 4 (1934) 449–453. [20] B. Krakow, R. Kellner, D. Pathak, et al., Imagery rehearsal treatment for chronic nightmares, Behav. Res. Ther. 7 (1995) 837–843. [21] B. Krakow, A. Zadra, Clinical management of chronic nightmares: imagery rehearsal therapy, Behav. Sleep Med. 4 (2006) 45–70. [22] B. Krakow, M. Hollifield, L. Johnston, et al., Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder, JAMA 286 (2001) 537–545. [23] J.L. Davis, D.C. Wright, Exposure, relaxation, and rescripting treatment for trauma-related nightmares, J. Trauma Dissociation 7 (2006) 5–18. [24] B. Moore, B. Krakow, Imagery rehearsal therapy for acute posttraumatic nightmares among combat soldiers in Iraq, Am. J. Psychiatry 164 (2007) 683–684. [25] S. Grandi, S. Fabbri, N. Panattoni, et al., Self-exposure treatment of recurrent nightmares: waiting-list-controlled trial and 4-year follow-up, Psychother Psychosom. 75 (6) (2006) 384–388. [26] J. Lancee, V.I. Spoormaker, B. Krakow, J. van den Bout, A systematic review of cognitivebehavioral treatment for nightmares: toward a well-established treatment, J. Clin. Sleep Med. 4 (5) (2008) 475–480, Review.

342 PART III | BSM Protocols for Pediatric Sleep Disorders [27] L. Wittmann, M. Schredl, M. Kramer, Dreaming in posttraumatic stress disorder: a critical review of phenomenology, psychophysiology and treatment, Psychother Psychosom. 76 (1) (2007) 25–39, Review. [28] L.J. Lamarche, J. De Koninck, Sleep disturbance in adults with posttraumatic stress disorder: a review, J. Clin. Psychiatry 68 (8) (2007) 1257–1270, Review. [29] V.I. Spoormaker, M. Schredl, J. van den Bout, Nightmares: from anxiety symptom to sleep disorder, Sleep Med. Rev. 10 (1) (2006) 19–31 Epub 2005 Dec 27. Review. [30] M.J. Maher, S.A. Rego, G.M. Asnis, Sleep disturbances in patients with post-traumatic stress disorder: epidemiology, impact and approaches to management, CNS Drugs 20 (7) (2006) 567–590, Review. RECOMMENDED READING B. Krakow, Sound Sleep, Sound Mind, Wiley & Sons, Inc., Hoboken, NJ, 2007. B. Krakow, J. Krakow, Turning Nightmares into Dreams, New Sleepy Times, Albuquerque, NM, 2002. B. Krakow, E.J. Neidhardt, Conquering Bad Dreams & Nightmares, Berkley Books, New York, NY, 1992. B. Naparstek, Staying Well with Guided Imagery, Warner Books, New York, NY, 1995.

Behavioral Treatments for Sleep Disorders. DOI: © Elsevier Inc. All rights reserved. 343 10.1016/B978-0-12-381522-4.00036-5 2011 Moisture Alarm Therapy for Primary Nocturnal Enuresis William J. Warzak Munroe-Meyer Institute for Genetics and Rehabilitation, Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska Patrick C. Friman Director of Boys Town Center for Behavioral Health, University of Nebraska Medical Center, Boys Town, NE PROTOCOL NAME Moisture alarm therapy for primary nocturnal enuresis. GROSS INDICATION Nocturnal enuresis, or enuresis, is a very common parasomnia affecting 5–7 million children annually. It is largely an inherited condition wherein children involuntarily pass urine while asleep. The moisture alarm is the single best evidence-based intervention to treat this disorder. SPECIFIC INDICATION Alarm treatment is indicated for children with primary enuresis (children have not been fully continent for at least 6 months) and secondary enuresis (children who have been continent for at least 6 months but relapsed). Alarm treatment is especially indicated for children who are monosymptomatic (incontinent only while sleeping at night). Most alarm trials have been restricted to children 5 years of age and older [1]. CONTRAINDICATIONS A small subsample of enuretic children exhibit clinical features suggestive of lower urinary tract dysfunction. These children are more likely to be wet during the day (i.e., have daytime incontinence) and exhibit other symptoms such as increased/decreased voiding frequency, voiding postponement, holding maneuvers, or staccato stream. Because alarm treatment is not typically indicated Chapter 36

344 PART III | BSM Protocols for Pediatric Sleep Disorders for these children, identifying them is critical, underscoring the importance of obtaining a medical examination prior to the inauguration of alarm treatment. RATIONALE FOR INTERVENTION Nocturnal enuresis affects 15–20 percent of 5-year-old children, with as many as 10 percent of those children remaining wet at 10 years of age. Prevalence rates tend to be somewhat higher for boys than girls throughout. By 12 years of age, approximately 8 percent of boys and 4 percent of girls continue to be enuretic [2]. Treatment is often deferred until age 6 or 7, because enuresis shows a steady decline with age and has an annual spontaneous remission rate of approximately 15 percent [3]. In addition, younger children may be less motivated to participate in treatment. After the age of 6 or 7, however, numerous reasons for treatment arise. For example, nocturnal wetting episodes inexorably interfere with participation in recreational activities (such as sleepovers, overnight trips, and camp), thus imposing an obstacle to important social and developmental experiences. Chronic bedwetting also can result in sleep disruption for the child and other family members [4]. In addition, incontinence is a leading cause of child abuse [5]. Finally, for all of the above reasons, a child with enuresis may develop an unhealthy low self-regard that interferes with effective psychosocial development. There are a number of medications used for treatment of enuresis (e.g., desmopressin, tolterodine, imipramine, and oxybutinin), none of which are indicated as front-line treatment for several reasons. For example, medication yields much lower levels of success than that produced by the moisture alarm. Additionally, the effects, when produced, typically occur only while the medication is taken, and dissipate when medication is discontinued. Perhaps most importantly, each medication produces problematic side effects, and occasionally significant health risk. For example, the Food and Drug Administration has recently ruled that the intranasal form of desmopressin is inappropriate as a treatment for enuresis because of its relationship to cardiac risk in a small number of patients. Nevertheless, although not indicated as a primary intervention, medicine should be considered if alarm therapy is unsuccessful. STEP BY STEP DESCRIPTION OF PROCEDURES 1. Selecting the right time to begin. Most typically developing children will acquire some measure of voiding control between the ages of 3 and 4, and by 5 years of age many children will have achieved nocturnal and daytime continence. Nevertheless, 15–20 percent of these children will be enuretic, and many professionals, if not parents, may choose not to intervene at this age, especially if the child is not deemed to be at risk. However, children who continue to wet the bed after 7 years of age should be considered candidates for intervention.

Chapter 36 | Moisture Alarm Therapy for Primary Nocturnal Enuresis 345 2. Preliminary evaluation by a physician. Before treatment begins, the child should be evaluated by a physician. The evaluation should include a brief neurologic exam, urinalysis, and perhaps a urine culture, to exclude factors that might suggest symptoms of lower urinary tract dysfunction, or identify co-morbid conditions, such as diabetes insipidis, spina bifida, or spinal cord trauma, that might influence treatment outcome. In addition, sleep disorders that may affect enuresis, such as sleep apnea, obstructive tonsils, mouth breathing or snoring, need to be evaluated as possibly contributory to enuresis. 3. Education and demystification. Children and their parents are often the victims of misinformation regarding enuresis. It is often helpful to identify other members of the child’s family that exhibited enuresis in childhood. In addition, it may be helpful to inform the child that there are many children their own age, some of whom may be their classmates, who also wet the bed. Children and their parents also should be assured that enuresis is often a heritable condition, and is not the result of psychological attributes such as laziness or stubbornness. Furthermore, the biobehavioral nature of enuresis is such that it is not possible for enuretic children to control their condition independently, and therefore punishment of wetting episodes is never appropriate. Finally, parents and children should be informed that the alarm may not be effective for several weeks. One method for tracking slow progress is to measure the size of the urine spot (which typically shrinks during treatment) and monitor the amount the child voids in the toilet following alarm onset (which typically increases over time of treatment). 4. Interview by behavioral health staff. Following the medical exam, the behavioral health professional should conduct a thorough evaluation that obtains information on all conditions that are relevant to alarm treatment. These conditions include any that could complicate or contraindicate treatment. At a minimum, the evaluation should include the following. – Age of daytime dryness may shed light on the developmental status of the child, and this, in turn, may affect training expectations. – Family history of bed-wetting may influence expectations of when the child may achieve dryness given no intervention. – Severity and frequency of the bed-wetting certainly affects expectations regarding successful treatment in the short-run, with more frequent wetting and multiple wettings per night being adverse predictors of success. – Daytime symptoms of dysfunctional voiding may considerably alter treatment planning. A history of difficult or painful urination, hesitancy, urgency, or daytime wetting suggests non-monosymptomatic enuresis, and may indicate additional assessment and treatment procedures over and above the moisture alarm. Similarly, symptoms such as giggle

346 PART III | BSM Protocols for Pediatric Sleep Disorders incontinence, stress incontinence (i.e., incontinence upon physical exertion), post-void dribbling, overactive bladder, and Hinman syndrome indicate additional assessment and potential referral to a urologist. – Current medications also may affect elimination. The use of enuresisrelated medications (and their history of use), such as desmopressin (DDAVP), imipramine (Tofranil), oxybutin (Ditropan), and tolterodine (Detrol), should be ascertained. Other medications that may indirectly affect enuresis by contributing to constipation, or altered sleep–wake cycles, also should be identified. – Co-morbidities (e.g., ADHD, diabetes insipidus) often influence treatment, if only because significant health issues complicate structured routines. – Constipation or bowel irregularity is common among enuretic children. Constipation can interfere with bladder function by impinging on the bladder and/or by inhibiting its natural expansion as it fills. – School issues may influence the ultimate success of treatment for enuresis or constipation. For example, if school schedules preclude sufficient opportunities to drink during the school day, the student may compensate by drinking more fluids during the afternoon and evening hours, thereby contributing to urine formation in the evening or after bedtime. – Food sensitivities may affect a variety of children. These do not include allergies, but rather reactions to substances within foods that can affect urodynamics. Examples include caffeine and tryptophan. – Compliance issues are crucial. Levels of compliance should be obtained for all children considered for alarm therapy. Children who are not under effective instructional control are poor candidates for the moisture alarm. For these children, it may be more effective to implement compliance training prior to implementing a full treatment plan including the moisture alarm. – Motivation to participate in alarm procedures is important to achieving success. An older child’s motivation to be dry often increases as the social limitations imposed by enuresis increase. However, younger children whose social functioning has not yet been significantly affected by the limitations imposed by enuresis may benefit from structured programming to increase compliance. An optimal motivational system would provide rewards for compliance with alarm procedures rather than for dry nights, which result from a combination of factors, many of which are beyond the child’s control. 5. Moisture alarm procedural checklist. Successful implementation of alarm therapy requires consideration of supplies and procedures. Important Supplies l An alarm that has a salient wake-up cue. Auditory alarms have the most supportive data but vibrating alarms have been shown to be effective, and

Chapter 36 | Moisture Alarm Therapy for Primary Nocturnal Enuresis 347 may be preferred when incontinent children share a bedroom. Alarms are widely available online from $50.00–$100.00 (e.g., www.bedwettingstore. com). l Alarm batteries (and extra set of batteries). l Clips and fasteners to attach the alarm to the child’s undergarment. l T-shirt to control wires, if any, from the moisture sensors to the alarm. l Snug-fitting cotton panties or briefs are preferred. l Mattress cover. l Nightlight in the bathroom. l Parents may need a baby monitor if their bedroom is far removed from their child’s. Important Procedures l Reassure the child that the procedure is safe and will not hurt. l Carry out a trial run prior to bedtime to demonstrate how the alarm works and feels (i.e., model the entire procedure and then have the child imitate the procedure). l Start each night with a clean bed. l Ensure double voids before sleep. Parents should have the child void during the pre-bedtime routine, and have them void one more time before actually going to bed. l Place sensor with consideration of boys’ and girls’ physiology. l Give the child responsibility for clean-up, as necessary. Parents must convey to their child that the child’s assistance is a matter of responsibility, and is not intended as punishment. l Data collection is completed by the child (with parental assistance as needed) each morning. l Deliver reinforcers, rewards, etc., contingent upon compliance with alarm procedures. Procedural Sequence 1. Prepare the child for bed consistent with proper sleep hygiene, including double voiding. 2. Attach the alarm appropriately to the child’s undergarment as directed by the manufacturer. 3. Turn on baby monitor, if applicable. 4. When the alarm sounds, if the child has not awakened, a parent/guardian should immediately wake the child. For example, the parent may call the child’s name, shake him or her until awake, or wipe the child’s face with a damp washcloth. Regardless, the goal is to have the child awaken, toilet him- or herself, and participate in clean-up procedures independently.

348 PART III | BSM Protocols for Pediatric Sleep Disorders 5. Wakefulness may be demonstrated by having the child count backwards from 10 or answer a question of the parent’s choosing. 6. Upon awakening, the child should disconnect the alarm, walk to the bathroom, void in the toilet, and complete cleanliness hygiene. 7. Following the bathroom visit, the child should mark his or her calendar to indicate a wetting episode, assist with bedclothes clean-up as stipulated by the parent, reattach the alarm, and return to bed. 8. Upon awakening in the morning, parents should provide the agreed-upon reward for participation in alarm procedures, as appropriate. POSSIBLE MODIFICATIONS/VARIANTS There are treatment packages that incorporate the above components as well as a number of additional features, such as cleanliness training, positive practice, awakening schedules, etc. The two foremost packages are Dry Bed training [6] and Full Spectrum Home Training [7]. Both of these packages require considerably more effort than the moisture alarm alone, and a discussion of them is beyond the scope of this chapter. Nevertheless, they provide additional resources to the child and family having difficulty achieving night-time continence. Children who relapse at the conclusion of treatment are often successful if provided a renewed alarm trial. In addition, these children may benefit from overlearning – a procedure in which success with the alarm is followed by a 2-week fluid challenge, typically 8 oz of water at bedtime, followed by alarm trials until dry nights are re-established. Dry bed criterion is typically 14 consecutive dry nights. Treatment failures may result from numerous causes, some of which are matters of adherence. Perhaps the most common cause of failure is premature termination of the alarm procedure. There is ample literature to suggest that the alarm often requires a 10- to 12-week course of treatment, and parents need to be apprised of this. Other sources of failure arise within the context of matching procedures to children, and these may be addressed with modifications of the standard procedure. For example, it is not uncommon for children to sleep through the alarm, and some enuretic children may actually have a higher auditory arousal threshold than non-enuretic children. Parents should be prepared to awaken the child upon onset of the alarm. They may need to incorporate an auditory monitoring device, such as a baby monitor, if the parental bedroom is too far away for parents to hear the alarm. Other children are comfortable with the procedure at home, but are confronted with obstacles to implementation if they attend a sleep-over – in which case, a sleeping bag with a liner and a change of clothes stored in the bottom of the bag may be an appropriate stop-gap procedure for the night. Finally, water restriction, possibly the most widely used method for managing enuresis (by parents and professionals), is unpleasant, and possibly even harmful to the child. There is no evidence that restricting fluids prior to bed

Chapter 36 | Moisture Alarm Therapy for Primary Nocturnal Enuresis 349 (unless a child clearly over-indulges) has any positive effect on treatment. In fact, there is evidence that many of these children are insufficiently hydrated, and fluid restriction at bedtime, after dinner, etc. merely compounds that problem. PROOF OF CONCEPT/SUPPORTING DATA/EVIDENCE BASE The diversity of research methods used to evaluate the moisture alarm contrasts sharply with the singularity of the findings they produce. Regardless of method, case report, case study, controlled group trial, or comparative group trial, research on alarm treatment routinely yields successful outcomes, perhaps in part because it teaches specific continence skills. Results from case reports and studies range as high as 100 percent successful with 0 percent relapse, and results from controlled trials range as high as 80 percent successful and as low as 17 percent for relapse. More generally, the collective evaluation research on alarm treatment shows that its success rate is higher and its relapse rate is lower than any other method [4,8–10]. On the strength of this body of research, prominent enuresis investigators have argued that alarmbased treatment meets the rigorous “Chambless” criteria [11] for effective treatment of enuresis [12]. In conclusion, the moisture alarm is a robust and routinely effective intervention, and should be the first-line treatment for most children with monosymptomatic enuresis. REFERENCES [1] C.M.A. Glazener, J.H.C. Evans, R.E. Peto, Alarm interventions for nocturnal enuresis in children, Cochrane Database of Systematic Reviews (Issue 2) (2005). Art. No.: CD002911. DOI: 10.1002/14651858.CD002911.pub2. [2] R.T. Gross, S.M. Dornbusch, Enuresis, in: M.D. Levine, W.B. Carey, A.C. Crocker, R.T. Gross, (Eds.), Developmental-Behavioral Pediatrics, W.B. Saunders, Philadelphia, PA, 1983, pp. 575–586. [3] W.I. Forsythe, A. Redmond, Enuresis and spontaneous cure rate: study of 1129 enuretics, Arch. Dis. Child. 49 (1974) 259–269. [4] P.C. Friman, W.J. Warzak, Nocturnal enuresis: a prevalent, persistent, yet curable parasomnia, Pediatrician 17 (1) (1990) 38–45. [5] R. Helfer, C.H. Kempe, Child Abuse and Neglect, Ballinger, Cambridge, MA, 1976. [6] N.H. Azrin, T.J. Sneed, R.M. Foxx, Dry-bed training: rapid elimination of childhood enuresis, Behav. Res. Ther. 12 (3) (1974) 147–156. [7] J.P. Whelan, A.C. Houts, Effects of a waking schedule on the outcome of primary enuretic children treated with full-spectrum home training, Health Psychol. 9 (1990) 164–176. [8] P.C. Friman, Encopresis and enuresis, in: M. Hersen, D. Reitman, (Eds.), Handbook of Assessment, Case Conceptualization, and Treatment, Vol 2, Children and Adolescents, Wiley, Hoboken, NJ, 2007, pp. 589–621. [9] P.C. Friman, Evidence based therapies for enuresis and encopresis, in: R.G. Steele, T.D. Elkin, M.C. Roberts, (Eds.), Handbook of Evidence-based Therapies for Children and Adolescents, Springer, New York, NY, 2008, pp. 311–333.

350 PART III | BSM Protocols for Pediatric Sleep Disorders [10] A.C. Houts, J.S. Berman, H. Abramson, Effectiveness of psychological and pharmacological treatments for nocturnal enuresis, J. Consult. Clin. Psychol. 62 (1994) 737–745. [11] D.L. Chambless, S.D. Hollon, Defining empirically supported therapies, J. Consult. Clin. Psychol. 6 (1) (1998) 7–18. [12] M.W. Mellon, M.L. McGrath, Empirically supported treatments in pediatric psychology: nocturnal enuresis, J. Pediatr. Psychol. 25 (2000) 193–214. RECOMMENDED READING P.C. Friman, M.L. Handwerk, S.M. Swearer, et al., Do children with primary nocturnal enuresis have clinically significant behavior problems? Arch. Pediatr. Adolesc. Med. 152 (1998) 537–539. G.A. Gimpel, W.J. Warzak, B.R. Kuhn, J.N. Walburn, Clinical perspectives in primary nocturnal enuresis, Clin. Pediatr. 37 (1998) 23–29. K. Hjalmas, T. Arnold, W. Bower, et al., Nocturnal enuresis: An international evidence based management strategy, J. Urol. 171 (2004) 2545–2561. W.J. Warzak, Psychosocial implications of nocturnal enuresis, Clin. Pediatr. 32 (July Special Edition) (1993) 38–40. N.M. Wolfish, R.T. Pivik, K.A. Busby, Elevated sleep arousal thresholds in enuretic boys: clinical implications, Acta Paediatr. 86 (1997) 381–384.

Behavioral Treatments for Sleep Disorders. DOI: © Elsevier Inc. All rights reserved. 351 10.1016/B978-0-12-381522-4.00037-7 2011 Promoting Positive Airway Pressure Adherence in Children Using Escape Extinction within a Multi-Component Behavior Therapy Approach Keith J. Slifer Pediatric Psychology Program, Department of Behavioral Psychology, Kennedy Krieger Institute, Baltimore, MD Departments of Psychiatry and Behavioral Sciences and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD PROTOCOL NAME Promoting positive airway pressure adherence in children using escape extinction within a multi-component behavior therapy approach. GROSS INDICATION Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPAP) are types of mechanical respiratory assistance prescribed for individuals with breathing disorders. Examples of such disorders in children include hypoventilation, hypercarbia, obstructive sleep apnea, and central apnea. PAP has been used successfully in infants and children; however, behavioral tolerance and adherence with these devices pose a significant challenge in pediatrics. When PAP is not successful with children, the vast majority of the time it is because of poor behavioral tolerance and therefore poor adherence. Behavior therapy protocols have been used to increase child tolerance of and adherence to PAP therapy, and there is published preliminary evidence to support effectiveness of these protocols with preschool and school-aged children. SPECIFIC INDICATION There are specific pulmonary indications for using these different breathing therapies, but for the purposes of this chapter dealing with children’s Chapter 37

352 PART III | BSM Protocols for Pediatric Sleep Disorders adherence with these technologies, they will be referred to as Positive Airway Pressure (PAP). While these devices were originally used in intensive care and acute care hospital settings, they are now routinely prescribed by pulmonologists for home management of some types of breathing disorders during hours of sleep, in individuals of all ages. Behavior therapy to increase cooperation and adherence with PAP regimens is indicated for children of all ages, including those with intellectual and developmental disabilities. However, there is some preliminary evidence that behavior therapy for PAP tolerance and adherence is more easily accomplished with children who are older and cognitively are more typically developing. In infants, young children, and those with intellectual or developmental disabilities the behavior therapy is focused on the caregiver – child dyad, and its success is dependent upon the caregiver’s ability and motivation to modify his or her own behavior patterns. There is no published evidence to suggest that behavioral therapy is more effective for any particular type of breathing disorders or specific medical diagnoses or syndromes. CONTRAINDICATIONS There is no research evidence to support any particular contraindications for behavior therapy. However, clinical judgment and experience suggest that children who are medically too fragile to tolerate increased levels of physical exertion and arousal are not good candidates for this type of behavior therapy. Using carefully graduated exposure to the PAP equipment and routine decreases physical arousal and exertion that may be experienced during behavior therapy. Nonetheless, emotional arousal and physical exertion may not be completely avoidable. This is especially true during escape prevention (escape extinction) procedures, when crying and some degree of physical resistance may occur. Therefore, the child’s ability to tolerate the amount of arousal and physical exertion that typically occur during a crying spell or tantrum must be verified with the child’s pediatrician or pulmonologist in order to safely employ the escape extinction component of the behavior therapy protocol described below. Another contraindication would be if the child has severe aggressive or self-injurious behavior. In such cases, the behavioral protocol below should be employed only with the assistance of a behavioral psychologist or behavior analyst who has expertise in managing these types of behavior problems. In some cases, overall parenting skills may be limited by cognitive difficulties or other psychosocial factors that interfere with learning or implementing the behavioral protocol. These caregivers may also have great difficulty managing their children in a variety of home and community settings, suggesting that more fundamental behavioral parent training may be needed before expecting them to implement a PAP adherence protocol. Finally, if the parent or caregiver is opposed to behavior therapy that may cause temporary increases in child distress, then success with a behavioral protocol may not be possible.

Chapter 37 | Promotion Positive Airway Pressure Adherence 353 RATIONALE FOR INTERVENTION PAP has been used successfully in infants and children; however, behavioral tolerance and adherence with these devices pose a significant challenge in pediatrics. When PAP is not successful with children, the vast majority of the time it is because of poor behavioral tolerance and therefore poor adherence. This is particularly the case for preschool-aged children, and those with developmental disabilities, anxiety, or behavior problems. These children commonly resist (verbally, emotionally, and physically) attempts to put on the mask by crying, head turning, and using their hands to cover their faces or push away the mask. Many develop conditioned anxiety because the sight, sound, and physical sensation of PAP become associated with discomfort from the pressure of the mask, the airflow into the nostrils, and physiologic arousal from struggling to resist the mask. Children learn very quickly that these behaviors often result in discontinuation of the caregiver’s efforts to apply the mask. In this way, these escape/avoidance behaviors are strengthened through negative reinforcement (they make the non-preferred sensations go away). A multi-component behavior therapy protocol can be used to increase child tolerance of and adherence to PAP therapy. This behavior therapy approach is based on the concept of escape extinction, which involves ensuring that the mask is placed by the caregiver despite the child’s escape/avoidance behaviors. If the child manages to displace or remove the mask, it is immediately replaced by the caregiver and only removed after a pre-designated period of adherence, and only removed by the caregiver at the appropriate time. The objective is to remove any negative reinforcement of escape/avoidance behaviors. However, escape extinction procedures should be embedded within the positive context that can be created by also using distraction, counterconditioning, stimulus fading for graduated exposure to the mask/air pressure, and differential positive reinforcement to shape cooperation and adherence. Without these other techniques to create a positive context, escape extinction alone would be simply coercive and unpalatable to most caregivers. There is published preliminary evidence to support the effectiveness of these behavioral protocols with preschool and school-aged children. In order to increase adherence with PAP, children must learn to relax and tolerate the novel and non-preferred stimulation involved with wearing the mask and experiencing air pressure into the nostrils and airway. When a child experiences uncomfortable stimulation, he or she will instinctively attempt to withdraw from it, to escape its proximity, and to avoid it in the future. If the experience is very intense during a single exposure, or is repeated often, the child is likely to develop conditioned anxiety (conditioned autonomic nervous system arousal) when exposed to sights, sounds, or smells that have been associated with the uncomfortable stimulation. The child may develop a conditioned avoidance response such that whenever the stimuli associated with PAP are encountered (sight of the mask or machine), he or she becomes physiologically aroused and attempts to physically avoid or escape the situation. Children

354 PART III | BSM Protocols for Pediatric Sleep Disorders may exhibit a variety of escape-avoidance motivated behaviors when they are anticipating an uncomfortable sensation. These behaviors may include crying, head turning, pushing away, running, hiding, hitting, kicking, spitting, etc. Many caregivers respond to these behaviors by attempting to comfort, coax, or reason with the child to calm him or her and obtain cooperation. Caregivers often learn to avoid the child’s distress and disruptive behavior by removing and/or protecting the child from the threatening situation. In this way, both child and parent behavior is motivated and shaped by escape and avoidance. Caregivers who are attempting to implement PAP typically react to child distress by trying to calm the child using verbal explanations, coaxing, apologies, expressions of affection, and removing the mask. This only strengthens the distress and, escape and avoidance behaviors. With repetition of this parent– child interaction pattern the child develops a varied and persistent repertoire of distress and escape behavior in response to the mask, and caregivers give up on implementing the PAP regimen. Thus, the goals of behavior therapy to enhance adherence with PAP are to decrease or eliminate the escape/avoidance function of distress behavior, and to positively reinforce approaching, wearing, and, ultimately, sustained adherence with the mask and air pressure for the prescribed duration of the PAP regimen. As will become clear in reading the step by step procedures presented below, the multi-component protocol is time- and procedure-intensive, and for many children and their caregivers will require the assistance and guidance of a specialized professional. This can be costly in terms of time and resources devoted to behavior therapy. These costs are justifiable in relation to either the negative health and cognitive consequences of a lifetime with sleep-disordered breathing, and PAP non-adherence. They also are justifiable when compared to the alternative, more invasive medical intervention for obstructive sleep apnea: surgical placement of a tracheostomy tube. This surgery is associated with all the risks of complications that accompany any major surgery. It might also not be effective for a child with behavior problems that may be as likely to disrupt or remove the breathing tube as they are to remove a PAP mask. In such cases, behavior therapy may be required anyway to prevent the child removing the tracheostomy tube. On the other hand, once a child and caregivers have successfully participated in behavior therapy for PAP adherence, behavior therapy can be discontinued and the PAP integrated into the child’s life like other daily care activities (bathing, toileting, brushing teeth). In short, PAP becomes part of the child’s bedtime routine. STEP BY STEP DESCRIPTION OF PROCEDURES The PAP adherence training protocol is implemented using a combination of behavior therapy techniques. These include: (1) conducting a task analysis of the regimen, (2) providing distraction from uncomfortable sensations using preferred activities, (3) counter-conditioning emotional arousal by providing

Chapter 37 | Promotion Positive Airway Pressure Adherence 355 preferred activities to induce a relaxed, positive state, (4) maintaining the child’s positive state while gradually exposing him or her to the steps in the task analysis and the associated sensations, (5) differential reinforcement of partial adherence by providing contingent praise and positive events (including mask removal by the therapist after a given interval of child adherence), and (6) placing escape/ avoidance behavior on extinction (by interrupting, blocking or redirecting these behaviors). Measurement of PAP Adherence Adherence with PAP therapy can be assessed and recorded using a task analysis format, which breaks down the child behavior required for adherence into sequential observable steps. Koontz and colleagues [1] published a task analysis of PAP that can be used to record child adherence for each step that the child completes or tolerates. Using this task analysis set up as a data sheet, one can score each step completed (e.g., within 10 seconds of a verbal prompt, with or without assistance, and without escape-avoidance behavior; see Table 37.1). Using this information, the percentage of steps of the task analysis that are completed by the child can be calculated (number of steps completed divided by the total number of steps in the task analysis, multiplied by 100). This type of measurement can be used during and across behavior therapy sessions to document the child’s success and progress. After the child is able to tolerate the mask and air pressure for more than a minute without distress, adherence data can be recorded in terms of minutes or hours of use. If staff resources are available, this can be accomplished by keeping 24-hour written records based on observation of the child at regular time intervals (e.g., every 30 minutes) and recording whether or not the child is asleep or awake, the mask is in place, and the device is operating properly. In most cases, this level of direct observation will not be possible. For example, in the home a parent cannot stay up all night to observe and record every 30 minutes. Alternatively, the parent can record: (1) what time the mask was placed, (2) what time the child fell asleep with the mask on, (3) what time the child awakened, and (4) whether or not the mask was still in place. Based on this information, the duration of PAP adherence can be quantified. Parents may choose to set an alarm clock and check their child at planned intervals throughout the night. Parents can be alerted to mask removals by the monitor alarm that is available on many PAP machines, or the low oxygen saturation limit alarm on a child’s pulse oximeter. In this way, each time the mask is dislodged or removed the parent can be alerted, intervene to replace the mask, and record the time of these events. For parents who are heavy sleepers, the monitor or oximeter alarm can be amplified using a commercially available baby monitor with the microphone placed in the child’s room and the speaker located on the parent’s night stand. Finally, many PAP machines are equipped with a Smart Card (Respironics, Inc., Murrysville, PA; www.respironics.com) or

PART III | B 356 TABLE 37.1 PAP Task Analysis Step Tolerance/ Cooperation? ✓ Attempts to Avoid or Escape? ✓ Crying or Negative Vocalization? ✓ 1. The child sits on the bed or stretcher. 2. The child cooperates with having the PAP cap placed on the back of the head. 3. The child lies in the supine position on the bed/stretcher. 4. The child remains supine and calm while the mask (not attached to the hose or cap) is placed in position on the face for 5 seconds. 5Thechildremainssupineandcalmwhilethemask(notattachedtothehoseorcap)is

BSM Protocols for Pediatric Sleep Disorders 5. The child remains supine and calm while the mask (not attached to the hose or cap) is placed in position on the face for 10 seconds. 6. The child remains supine and calm while the mask (not attached to the hose or cap) is placed in position on the face for 1 minute. 7. The child remains supine and calm while one side of the mask is attached to the cap. **Prior to next step, the mask will need to be connected to the tube and the tube will need to be connected to the machine. 8. The child remains supine and calm while the mask (attached to the hose and one side of the cap) is placed in position on the face and while the air is turned on for 3 seconds. 9. The child remains supine and calm while the mask (attached to the hose and one side of the cap) is placed in position on the face and while the air is turned on for 5 seconds. 10. The child remains supine and calm while the mask (attached to the hose and one side of the cap) is placed in position on the face and while the air is turned on for 10 seconds.

Chapter 37 | Promotion Positive Airway 11. The child remains supine and calm while the mask (attached to the hose and one side of the cap) is placed in position on the face and while the air is turned on for 1 minute. 12. The child remains supine and calm while the mask is placed in position on the face and is connected to the cap on both sides. 13. The child remains supine and calm while the mask (attached to hose and both sides of the cap) is placed in position on the face and while the air is turned on for 1 minute. 14. The child remains supine and calm while the mask (attached to hose and both sides of the cap) is placed in position on the face and while the air is turned on for 5 minutes. 15. The child remains supine and calm while the mask (attached to hose and both sides of the cap) is placed in position on the face and while the air is turned on for 10 minutes. 16. The child remains supine and calm while the mask (attached to hose and both sides of hldhfdhlhdf

Pressure Adherence 357 the cap) is placed in position on the face and while the air is turned on for 15 minutes. Reprinted with Permission from: K.L. Koontz, K.J. Slifer, M.D. Cataldo, & C.L. Marcus, Improving pediatric compliance with positive airway pressure: The impact of Behavior Intervention. Sleep, 26 (8) (2003) 1010–1015.

358 PART III | BSM Protocols for Pediatric Sleep Disorders similar electronic monitoring device, which may provide more accurate, objective adherence data. These devices automatically record data on when the PAP is running, the mask is in place, and the machine is functioning properly, indicating that the child is wearing the mask. However, these monitoring devices may not be available for all machines, and may not be covered by some health insurance providers. Another limitation of this technology is that it requires a computer and specific software to download and analyze the data. Therefore, in most cases these data would only be available when the Smart Card or its equivalent is taken to the physician’s office or clinic, and professional time is available to analyze and interpret the data. Initial Behavioral Assessment Before initiating behavioral treatment the child should be observed during one or more attempts to don the PAP mask at either naptime or bedtime, and initial adherence data recorded. These assessments should only progress through the PAP task analysis to the point where the child exhibits obvious distress and attempts to avoid or escape the mask or equipment. It is not necessary or wise to persist with these trials without behavioral intervention, because doing so will only reinforce the child’s distress and escape behavior. Reinforcer or Stimulus Preference Assessment Before attempting to implement the behavior therapy protocol, it is important to obtain information about the child’s favorite activities that might be used for relaxation, distraction, and motivation (e.g., snacks, bubbles, videogames, movies, singing, small rewards, etc.). This can be accomplished by interviewing the parent, having the parent or caregiver complete a reinforcement questionnaire [2], or conducting a more formal assessment where potentially reinforcing stimuli are presented in pairs to the child and the child’s hierarchy of choices is systematically determined [3–5]. The most highly preferred items are then either provided non-contingently (delivered independent of the child’s behavior) to distract or relax the child during exposure to the PAP mask and air pressure, or presented contingent upon (immediately following and in response to) positive behavior such as direction following, cooperation, and coping with presentation of the PAP equipment and its accompanying sensations. Summary of Protocol Procedures The PAP adherence training protocol is implemented by conducting a task analysis of the regimen, providing distraction from uncomfortable sensations, counter-conditioning emotional arousal using preferred activities, gradually exposing the child to the steps in the task analysis and associated sensations, providing differential reinforcement for cooperation and mask tolerance via